Men who live in rural areas or small towns have an average life expectancy of 74 years, while their urban counterparts live an average of three years longer. Children who live in high-risk neighborhoods are 32 percent more likely to be diagnosed with asthma than children in low-risk communities. Similarly, unemployed adults are 55 percent more likely to suffer from heart disease than adults with full-time jobs.

These differences in health outcomes, which were outlined in the government’s Health Equity Report 2017, are known as health disparities—and they underscore the fact that entire populations of people don’t have the opportunity to be as healthy as they could be.

Health disparities fall across a range of dimensions including race, ethnicity, gender, education, income, and geographic location. These health disparities are often exacerbated by disparities in healthcare—that is, differences in the abilities of different populations to access the services they need to improve their health outcomes.

Reducing health disparities is a major goal of public health officials. The Health Resources and Services Administration (HRSA) has created many pathways for improving access to healthcare services among populations that have typically struggled to get necessary medical and behavioral healthcare.

One such pathway—the New Access Point Program—provides funding to community health centers to establish operations in medically underserved areas. The New Access Point program is so vital that HRSA has steadily increased its annual funding budget from $1.3 billion in 2002 to $5.5 billion today.

But to be truly effective, the grants must be directed to geographic areas where the need is greatest.

This seems obvious. What is less obvious is how to define “need.” What specific factors constitute need and how do you quantify them? How do you distinguish between an area of some need and an area of staggering need?

This is the challenge HRSA brought to MITRE in 2016. HRSA asked MITRE, in our role as operator of the CMS Alliance to Modernize Healthcare federally funded research and development center (the Health FFRDC), to help it incorporate a consistent assessment of service area need as a component of the overall application review process and to also reduce applicant burden. Sponsored by the Department of Health and Human Services (HHS) and administered by the Centers for Medicare & Medicaid Services (CMS), the Health FFRDC serves as an objective adviser to HHS and other federal agencies with health and human services missions.

“HRSA was committed to having a standard, transparent, automated methodology to determine where need was not being met,” says John Boiney, a MITRE social behavioral scientist who has served as project lead. “Because unless you have that kind of methodology, you're more likely to promote disparities than to resolve them. You may end up not funding centers that should be funded—and vice versa.”

MITRE’s approach to the problem resulted in the creation of the Service Area Needs Assessment Methodology, or SANAM. HRSA put this solution into practice during the 2019 New Access Points funding cycle, which accepted applications from January 11 through April 11 of this year. Grant recipients are expected to be announced on September 1.

As Easy as Looking up a ZIP Code

SANAM creates an overall numeric representation of unmet need by using publicly available data for 24 health and social determinants and health-status indicators.

The health determinants capture overarching drivers of health status, including social determinants such as poverty, educational attainment, and housing quality. They also include barriers to accessing healthcare including lack of insurance, access to transportation, and language issues. Health status indicators include the incidence of asthma, diabetes, tobacco use, and the mortality rate.

Each measure is assigned a weight that reflects its relative importance in the overall measurement of unmet need for the Health Center Program. By combining these weighted measures, SANAM generates an Unmet Need Score (UNS) for primary and preventive healthcare by geographic area. Finding the UNS is about as hard as looking up a ZIP code.

HRSA was so confident in the methodology that it accelerated the deployment so the system could be used to select 2019 grantees. MITRE supported the deployment by calculating the final scores and developing supporting materials.

“There were no technical issues identified during the grant cycle,” says Sam Steckley, who served as technical lead on the project. “It was fairly smooth sailing.”

Having MITRE, an independent, unbiased third party, develop the system has helped prospective grantees overcome concerns that commercial considerations might influence the need measures.

“The fact that we're not selling anything was really essential to the process,” Boiney says. “We were able to allay those fears.”

Ultimately, the new system should reduce application barriers for community health centers. Applicants no longer have to gather data and estimate unmet need for their proposed service areas. Instead, they can go directly to their game plan for providing services.

Refining SANAM Holds Promise for Solving Other Problems

To develop the method, MITRE brought together an interdisciplinary team. Public health experts and epidemiologists first combed through publicly available measures to assess and identify the determinants and health indicators that most accurately define the complicated and sensitive nature of need at the community level.

Next, data scientists and statisticians gathered and prepared the data and developed the model.

“We had a team that was uniquely qualified to take on this challenge,” says Grace Moon, who also served as a project leader. “They provided something that's never been done before. And now this work is going to affect how healthcare is provided to underserved Americans—that’s a pretty big impact.”

It may also be only the beginning. SANAM could be applied to other projects and other agencies that want to maximize the impact of their limited resources.

"The ability to have an evidence-based method of directing resources is a real breakthrough for HRSA and it could be for others as well," says Mark Thomas, Health and Human Services Portfolio Director at MITRE. "There are billions of dollars in grant funding going out to states and communities. Every agency wants to be sure those dollars are targeted to areas where they can be the most effective.”

By adjusting the measures used to assess unmet need, SANAM could be applied to other areas, such as child and adolescent welfare and education, maternal health, and substance use disorder.

HRSA may also want to continue advancing the tool. The agency has begun discussions with MITRE on further refining the methodology. Refinements may include adding new measures to the existing framework and providing further geographic specificity. HRSA is also considering other potential applications of the core SANAM approach to other Health Center Program needs.

“We have persistent health disparities across geographic, racial, and ethnic groups,” says Paul Jarris, Chief Medical Advisor in the Health FFRDC. “By 2055, our nation will be majority minority, and health will decrease further if we do not eliminate avoidable disparities.

"We must take the lead in understanding social and structural determinants of health and how to impact them positively with our health, policy, informatics, analytics, and engineering expertise.”

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